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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS oWNER tIUIt,DER DELLNiA'I'ION
<br />I hcr.hy afllrr uidcr pcnalty ol lcdury rhd I aN cxctrrg lio,n lhc C.nracio Liccnsc LaLv ior Ihc lolbwins rua$r (s..7011 5
<br />lrusirc$ rnd Profc$ion Codc): Any Cily or Counry $hich rcluir$ 0 p.nnil b con{ru.r- dr&, impn,vc. dc dish or Nt{r Jny
<br />{tucrtrrr. prtn t, irs istrrncc. al$ r.quirc\ rh. lPllicrnl l{trsuch lf,nn k,lll.r \i8trcd sdrcmcnr lhdt hcor shc is li..nscd pu^uani
<br />t, rhc })Iorisions ol rhc C.nrracroi\ l-iccnrd Law ((]hrprcr 9- Connncnci',g wirI S..tn,n 7001) of Divisiotr 3 oflhe llusincs\ !nd
<br />Ptura\siotr\ Codc).r rhar hc.rshc iscxctrrpi rl[rclio rid rhc basis h hc rllcpcd cxcnrtrion. Any vid!rionotSc.rioi 70115 bt dny
<br />aDplicr lnr r F-flnir subjcclsrhc lprlicatrllo acivilpcn,lryofnornucrhnn iive hundrcd dollrs I $5m)
<br />l. trs owncr of rh. Imtcny. or hy .frplote.s eirh $ Ecr r rhet $h c. rl.nsd nt sill do rhc work ord lhc struclE is tror
<br />ilnc cd oi oliaicd f(tr ulc (Se ?04,1, Busincss otrd PNi!$iotrs Codc Thc Contrkn s Lkcn{ l-rw dd\ ioi rpply l. m owncr of
<br />Ih.pnp.dywhohildrdi'rtrovcsrh.N.oldwh.d6ssu.hsorkhi'nsclfnrhcnclforrhmu8hhisorhcrosnc'nPk,yccs,
<br />pr.vidcd rhrr such inprorcnrn^ m nor inrcnd.d or offs.d fn srlc lli )n,*cvcr. rtr bu ildiry or iDpmrc.Etrr is nld s irhi r ,,k )rr
<br />olcomplcliotr. lhc Owmr tluilds will hatc rhc burdctr olprovins lhar hc or shc dil Dor buiH or nnprov. D prcpcny for rhc ruqssc ot
<br />_l- rso*ncrofrhc pn,Fny, rmcrcldsivclrconr.rrin8 $irh li.cnsrd coiti.k,s to..rstn.r rlr fmjccr (Ss. 7044- Dlnrcss
<br />rnd Pldis\iri Codc Th.Conlracror'sLi.ctrscl-awdocsn.lamlyrortroNncroipopcnywhonuiusorioPnilesrhcr.on.
<br />ond who co mcts ior such DmjEls sirh ! Conrncro(s) liccnscd pur\ur nr rhc Contackr's Ltcn\. trw)
<br />-l
<br />rncxcnrfl n cr Sc!ri{)Il & t'C iirrhnrcx\nr
<br />cl - t4 - zo tL o."",
<br />DECI,IBA.III}!
<br />I hcrcby sflifln undd pcnaltyoircrjuryotrc oilhe rolhwin8 d(larrrions:
<br />I havc elwillnrinrsi', rCcnificrrcofconscnr r, s.lf lnsurcli, w.rkc(' .onDctrsrtror. rs pmvidcd i,x by sfttidr :l7oo of ihc
<br />Llll)l Codc- for lhc pcrtunnrncc .l rhc *u[ for which I hc pcoir is i$ucd
<br />lhJvcrndwillfHlnrninsorl.rfcortcNnri,n[\u.r...r\r.qurcdbtScclior:]700oirhcL$orCo,lc-i(nrhopcrfonmtcol
<br />rhc w.rl lo.$hichrhi\ pcrmir i\ isrucd. My*o crs.o rpci\rtoi nr\u1dr.c .:uricr dftl,,olicy nunrncr rc
<br />_l c.nilyrhri in rhc perr{rnLmcofrhc work r.r which rhis pcnnir i\ i*tr.d.1shrlltrol cm (,yr.y txN[ inrny rnncr
<br />R, st,h.$tr\uhjc.rL,rhc$orkcr\.ompci\a!o0laws.fCalihnrir.dmtagrcclhrli,IshouldhcconrcshF.rr,rl[
<br />wo*cri co'nFDsnrii,n ptuvi\i.ns ofSccrion lT(x)of rhc Lrhn G)dc.l shdll.lonhwith.onrrly tr'irh lho{ pnri\n,n\
<br />\rlAl{NING hiLurc h $.urc workcrj conrEnsrion .o\rrec is utrhwhn. an,l shrll \ul,rccr r tn{noy$ ro .rminnl ll.nilrtrr ird
<br />.ivil ftrcs ut b o c hutrdrL'd rhousrtrd dollars ($ltD.mo). ir lddirion ro lhc con .l .onDcn\rrnn,. dxitrgcs as rovidcd rir rhc
<br />sNli.n 1076..rh.1*nra:.n. inr.r.srr
<br />,,,". 4,.7'-1- zot$
<br />IECLAEAIION
<br />I hcrchylfli'nnrlcrprulry.fr.rjorr rh, I d li..n$d undcr pmvhiotr ot Chrlrd 9lcornEncing wirh Secrion 7000) ofDivisnrn:l
<br />oi rlr ltusircs.nd Profcsions Codc- md my liccnsc h ir lull lue lnd e,Tccr
<br />co mctor:
<br />IAN,IItsUSIIANU}NIIIIG-AIiENII
<br />I hcrchr rrfirm trRlcr lcmlry6fFguryrhd rhcrc is r..nntucrioo lcnding agcmy for rhc Frfornunce ofrhe sort frtr which rhis !.rmir t
<br />hsucd (Scc :109r. Civ C ).
<br />axEuca[LD]rcl,d.tsdu0N
<br />I lf,r$y afiinn u Mcr Nn,lry ol ncrjury oN ofthc folkNltrg dNid,rlions
<br />Drnx'liri. Pcnnih Ash.no\ Notifi.lrion Fcdcful R.8lhrnntr (l illc.{1. fttr16)
<br />Rcquncd IxIcr ol Norilicrri{nr
<br />l.cnllitlr rlr t dcRlrc8ulnti(nrs rcg:udirA r$teo\ r.nn,vtrl ,r Dor rpflicrbl. rorlh pojccr.
<br />lcnili rhar I ltr\r r J lh$appliorn rtu {.t. Ihd rhc rhrvc rtrlonM ion h cord l xgle b { ,!ly wnh dll C yrndCounty
<br />ordi'r ..s nid Sr.rdl-.$srcldingIo buildnr8 ..nnru.riotr. dhcrcbyruihorizcrcprcscnrarivcsotrhnCiryrndCoxnrylocntnupoDthc
<br />rhovc nrctrrioncd poNrty for irst€dion purF)ses.
<br /> ppricnnr orasenr sisnaiur: X,aA1 7- zt- zotQ,
<br />'z-
<br />t4)
<br />A
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />I
<br />FINAL ?/z//4 ^,,1b4,iCertif icale ol Occu nc
<br />Notes, Remarks, Etc
<br />Policy Nlmber:-Expires:
<br />-
<br />Li.cnscch*r Li.c sc NnnrtEr:
<br />-
<br />tr:,.. . \Jm..
<br />UFER Ground
<br />T-Bar
<br />Flood Zone Cerlif.
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